When you receive medical care from an out-of-network provider, the health insurance company does not usually pay the total amount the healthcare provider charges. Instead, they may pay a lower amount called “balance billing” or may cover part of it.
Most insurance plans decide how much to pay for out-of-network services based on their usual, customary and reasonable (UCR) charges or Medicare’s payment schedule.
How to Get Reimbursed
Health insurance plans generally have a network of medical providers they contract with to provide services at discounted rates. You may be charged out-of-network fees if you visit a doctor or hospital outside your network. These fees can be frustrating and expensive, especially if you’re paying out-of-pocket for your care.
Fortunately, there are ways to get reimbursed for the costs you spend on care from an out-of-network provider. It is essential to have an insurance plan that includes a deductible.
A deductible is the amount of money you must pay each year before your health plan starts to cover costs. If you meet your deductible, your healthcare plan covers out-of-network costs, too.
What to Do After You Get Reimbursed
It can be frustrating to receive unexpected medical bills and overpayments from health insurance companies, especially if your insurance could be a better fit for you. However, if you know how out-of-network reimbursement works, you can minimize the financial risk of receiving care from an out-of-network provider.
The majority of health plans have agreements with a network of physicians, medical facilities, and other service providers to offer members of the plans discounted services. The provider consents to treat patients who utilize their services as though they were their own in exchange for this discount. Healthcare providers use a Superbill as their primary data source for generating claims. These claims will eventually be forwarded to the payers for payment. An expert like Superbill is an itemized list of every service provided to a client.
Insurance companies typically pay out-of-network doctors at a rate that varies based on the service provided and the doctor’s location. In general, reimbursement rates for outside networks are higher than those for inside networks.
Some physicians may ask patients to show their health plan card or certificate before they render services. It is essential for patients because it ensures they have the right insurance coverage before receiving medical care.
If you need care from a doctor or hospital that’s not in your network, the ACA requires that your insurance company cover your treatment as if it were in-network. It includes emergency care.
It can also help to negotiate with your doctor or hospital directly. Some doctors or hospitals may offer you a discounted rate in exchange for paying cash or agreeing to a shorter payment time frame. The key is to stay calm and polite when negotiating with your health provider. You can also keep a paper record of your conversations.
What You Need to Know
As with all aspects of health insurance, educating yourself on your plan is essential. It will help you make more informed decisions about your healthcare and avoid surprise medical bills.
One way to achieve this is to review your insurance and the difference between in-network and out-of-network copays. You can find this information in your policy or your Explanation of Benefits (EOB) – a document your insurer sends you to explain what services are covered and why.
Most insurance plans have quality screening and monitoring programs to ensure that providers in their network meet specific standards for quality care. These include a range of factors, from the status of their licenses to recognized healthcare accrediting organizations.
Getting care outside your health plan’s network can also affect your out-of-pocket costs for standard treatments, such as doctor’s visits and prescription drugs. It is because out-of-network providers cannot contract with your health insurance provider and may charge a higher fee than in-network providers.
Another essential factor is how your out-of-network reimbursement works with your deductible. If your deductible is low, using out-of-network benefits could make getting the care you need easier while saving on insurance premiums.
New protections are being introduced to protect consumers from so-called “surprise” balance bills – when out-of-network providers charge you more than your insurance pays.
How It Works
Getting reimbursed from your health insurance company is complex and needs to be clarified. But understanding how it works will help you make the most of your out-of-network benefits and avoid pitfalls that could cost you money. In general, when you see an in-network provider for an office visit or outpatient care, your health insurance pays 80% of the “usual and customary” rate (also called the “reasonable and customary” or “AAA”). That means you pay the remaining 20%.
However, if you see an out-of-network provider, your insurance company will not have a contract with that doctor and may not negotiate a rate. It is why your price can be 30% higher than what you’d pay if you saw an in-network provider. Even if you see an in-network provider, unexpected costs can still be associated with your emergency. It is why the federal No Surprises Act protects you from balance billing.